Healthcare Provider Details

I. General information

NPI: 1225139298
Provider Name (Legal Business Name): PRO ACTIVE ADVANTAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 SHOUP AVE W
TWIN FALLS ID
83301-5029
US

IV. Provider business mailing address

562 SHOUP AVE W
TWIN FALLS ID
83301-5029
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-0407
  • Fax: 208-734-3534
Mailing address:
  • Phone: 208-734-0407
  • Fax: 208-734-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateID

VIII. Authorized Official

Name: LISA COLWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-734-0407